Cervicogenic HA
Clinical Findings |
Reduced Neck ROM |
Reproduced by moving the neck/pressure over C2 NR |
Ipsilateral Shoulder/Arm Pain |
Unilateral, Doesn't change sides |
C1-C3 NR affected |
Can present with Nausea, Vomiting, photo/phonophobia |
TrP in Upper Traps, Lev Scap, Scales + Suboccipital Extensors |
Weak Deep Neck Flexors |
Classfications
A. Pain referred from a source in the neck & perceived in >1 regions of the head/face + C+D |
B. Clinical,lab/imaging evident of a disorder/llesion within the cx or soft tissues of the neck known to be,or generally accepted as, a valid cause of HA (no cx spondylosis) |
C. Evidence of HA caused by neck dysfunction - criteria at least one of the following: |
1. clinical signs that point to a pain in the neck |
2. abolition of HA - diagnostic blockade of cx structure |
D. Pain resolves within 3 months of treatment |
Management
Physical Therapy: |
Cx Spine Mobilisation/Manipulation |
Upper Quartet/DNF strengthening |
Tx Spine Manipulations + Exercise |
Postural Training |
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Medications: |
Antidepressants |
Muscle relaxants |
Botox |
Steroid Injections/Nerve blocks |
Tension Type Headaches
S&S |
Bilateral, Pressing/tightening |
Mild-Moderate Intensity |
Can present with migraine symptoms (nausea, vomiting, photo/phonophobia |
Usually lasts minutes to days |
NOT WORSENED WITH PHYSICAL ACTIVITY |
Management
Cx Exercises |
Relaxation |
Massage |
Postural Exercises |
Cranio-cx technique |
1000mg paracetamol + 130mg caffeine |
Hypnic HA
S&S |
Headache that wakes patient up at night |
Can be unilateral/bilateral |
Begins abruptly |
Can have autonomic features |
Dull-moderate severity |
Responds well to lithium + caffeine |
Management
Exclude 2ndary HA - drug withdrawal, sleep apnoea, brain tumours, TA |
Exclude primary HA - migraines, cluster HA, chronic paroxysmal hemicrania |
Refer to GP - specialist |
Lithium/caffeine most effective |
Red Flags
- HA that is progressively worse over time |
- Sudden onset |
- Severe HA |
- New/unfamiliar HA |
- HA with head trauma |
- Unexplained weight loss |
- Impaired consciousness |
- Fever |
- Significant neck stiffness |
- Rash |
- Nuchal rigidity |
- Vertigo |
- Diplopia |
- Drop attacks |
- Difficulty speaking/swallowing/walking |
- Nystagmus |
SNOOP
- Systemic symptoms: Fever, weight loss, Cancer/HIV |
- Neurological signs: confusion, impaired alertness, consciousness |
- Onset: sudden/abrupt onset - develops and peaks quickly |
- Older: New HA in patients >50 years old (GCA, bleed, stroke) |
- Previous HA hx: new HA - different in frequency, severity and clinical features |
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Migraine
S&S |
Unilateral, severe pulsating/pounding HA |
Radiates to periorbital/retroorbital/frontal/temporal/ocular areas |
Nausea, photo/phonophobia, lack of appetite,mood/libido |
Can be with aura/without |
Scintillating scotoma (flashy,zigziggy lights - obstruct visual field) |
Can present with hemiplegia and cold extremities |
Prodrome, aura, attack, postdrome |
Lasts between 4 and 72 hours |
Prodrome: Lethargy, yawning, food cravings, mood changes, excessive thirst, fluid retention, constipation, diarrhoea, hypersensitivity to light, sound or odors |
Aura: Develops slowly over 5-20 minutes (distinguishes between TIA/stroke) - lasts up to an hour - Commonly visual disturbances (scintillating scotoma - a piece of absent vision with shimmering border), tunnel vision
Paresthesia is 2nd most common - numbness in hands and then up to arm, face , lips, tongue
Motor symptoms can be present - heaviness in limbs/speech and language disturbances |
Postdromal: Occur in hours following the attack - fatigue, irritability, euphoria, myalgia, food insensitivity/cravings |
Vital signs may reveal - bradycardia, tachycardia, hypertension, hypotension |
Observation can reveal Horner's syndrome (mild - ptosis and miosis) ipsilateral to HA Presence of papilledema = further investigation |
Palpate temporal artery in >50 yo |
Limited Cx ROM |
Assess cardiovascular/cebrovascular issues - migraine patients have an increased risk of cardiovascular disease |
Classification
- Migraine without aura |
- Migraine with aura (autonomic nervous system - occurs immediately prior to the headache |
- Visual disturbances, extremity paresthesia, nausea, vomiting, hypersensitivity to light/sound |
- IHS: Five episodic headaches, each lasting 4-72 hours + nausea/vomiting or photophobia/phonophobia with >2 of the chararacteristics:
moderate-severe intensity
unilateral presence
pulsating quality
aggravated by physical activity (can be bilateral and non-pulsating) |
Management
Drugs: Aspirin (900mg), ibuprofen(400-800mg), paracetamol (1g) - SSRA and ergot alkaloids, beta-blockers, tricuclic antidepressants, divalproex sodium, valproic acid (be careful of overuse headaches) |
Lifestyle Changes - identifying Triggers (Headache diary), if medication, patient should see their GP, dietary advice, hydration |
Massage of SCM, upper traps, splenius capitis, suboccipital, interscapular and shoulder girdle muscles |
Stress relief |
Cold pack @ back of neck |
SMT of Cx (be careful of risk of stroke) |
Strengthen DNF and postural advice for upper crossed |
Yoga |
Headache diary |
Aerobic exercise - 40 minutes 3x a week |
Magnesium, vitamin D, calcium, B6 supplements |
Botox injections |
Surgical care is discouraged |
Risk Factors/Demographics
- Mainly females more than males |
- High economic cost - lost workdays |
- Migraine without aura = peaks in boys aged 10 and girls aged 17 |
- Before puberty, migraine is more common in boys, after puberty its girls |
- peaks@ 3rd decade, decreases after 4th decade, new onset migraine HA after 50 is rare |
- Genetics |
-Obesity/overweight |
- Low cardiovascular fitness |
- Hypertension, hypercholesterolemia, impaired insulin sensitivity, coronary artery disease, hx of stroke |
- Medication overuse - acetaminophen, naproxen, aspirin, opiates, barbiturates, triptans |
- Hypocalcemia and vita D deficiencyy |
- Triggers - stress, smoking, strong odors, bright/flickering lights, fluorescent light, excessive/insufficient sleep, head trauma, weather changes, high humidity, motion sickness, cold stimulus, lack of activity/exercise, dehydration, hunger, hormonal changes, upper cx tension/cervicogenic HA |
- Medications - oestrogen, oral contraceptives, vasodilators, nitro-glycerine, histamines, reserpine, hydralazine, ranitidine |
- Food triggers - alcohol, excessive caffeine, artificial sweeteners, MSG, soy sauce, citrus fruits, papayas, avocados, red plums, overripe bananas, dried fruits, sour cream, buttermilk, nuts, peanut butter, sourdough bread, aged meats and cheeses, processed meats, anything fermented, picked, marinated |
Imaging
Not usually considered |
If pathology suspected - MRI |
If cerebral vascular pathology - aneurysm, vasculitis, arterial dissection - MRA |
DDx
- TTH (bilateral, non-pulsatile not aggravated by physical activity) |
- TIA/stroke (more quickly and lasts longer) |
- GCA |
- Cluster HA |
- Acute Glaucoma |
- Meningitis |
- Neoplasm |
- Cerebrovascular bleed |
Cluster HA (Rare) - TAC
S&S |
Excruciating unilateral periorbital/temporal pain |
Sharp, pulsating, pressure like pain - usually on the right side |
ipsilateral autonomic symptoms: Conjunctival injection & lacrimation, nasal congestion/rhinorhea, forehead/facial sweating, facial flushing, eyelid oedema, miosis,ptosis |
Restlessness & agitation |
Can present with Auras,photo/phonophobia, nausea + vomiting |
Pain in 1st trigeminal branch - always on same side of head |
Physical activity relieves pain |
Management
Avoid Triggers |
GP Referal |
Triptans, steroids, oxygen inhalation |
Occipital Neuralgia
S&S |
Piercing/throbbing in upper neck, back of the head, behind ears |
Unilateral |
Scalp tender to touch |
Photophobia |
Causes
Pinching of the nerves (greater + lesser) |
Tight muscles - microtrauma |
Too much extension for long periods |
OA |
Tumour in neck |
infection |
Gout |
Diabetes |
Vasculitis |
Management
Massage |
Rest |
Antidepressant |
Nerve block |
Steroids |
Treating underlying cause |
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